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Published on : Mar 14, 2014
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Slide 1 - Adolescent Back Pain(Quit yer whinin’…) Amy K Evans, PGY1 Adolescent Medicine National Naval Medical Center August 2005
Slide 2 - Case Presentation CC: College physical HPI: 19yo WM presents for routine physical. No current concerns. Oh wait, actually my back hurts. Past 4-6mo. Pain low mid-back just above belt level, band-like distribution but no radiation above or below. Occurs in AM after exercising day prior; gone by noon. Does not use heat, ice, or meds. No pain in buttocks or legs. No reported numbness/weakness. No specific hx trauma. PMHx: None Meds: None
Slide 3 - Case Presentation HEADSS: Younger brother, good family relationships Soph at Miami of Ohio Excellent grades Government major Basketball, LAX as club sports Girlfriend x9mo, no SA Occasional EtOH, no smoking, no drug use
Slide 4 - Case Presentation Physical Exam: AFVSS; Ht 75%; Wt 75% Exam unremarkable Back: symmetric, no scoliosis, no erythema/edema, no tenderness to palpation, no paraspinal spasm, FROM flex/ex Positive lumbar hyperextension test bilat LE: decreased hamstring flexibility (1/10), normal strength & sensation, FROM hips, knees, ankles
Slide 5 - Back Pain in Pediatrics Uncommon CC, but common occurrence 7% of 12yo with >1 episode LBP 50% of 18yo F, 50% of 20yo M Most not definitively diagnosed Most benign etiologies ~Half of episodes musculoskeletal (ER) 10% infectious, 13% idiopathic, 13% SCD Remember, backpacks <15-20% of weight!
Slide 6 - Back Pain in Pediatrics:Differential Diagnosis
Slide 7 - Red Flags! Infectious, Neoplastic, Rheumatologic Acute trauma Night pain Worsening pain Systemic symptoms Neuro symptoms Hx CA/TB exposure Severe disability Young age (<4yo)
Slide 8 - RedHawk’s Films
Slide 9 - What does he have? Spondylolysis: Defect (separation) in pars interarticularis Spondylolisthesis: Anterior slippage of vertebral body over next lowest body
Slide 10 - Spondylolysis Found in 7-8% of general population Found in 5% by age 6 Males>Females (2:1) Females more likely to progress to spondylolisthesis White>African-American Most commonly at L5 (90%; 80% bilat) Often asymptomatic/incidental finding
Slide 11 - Who is at risk? Genetic predisposition Alaskans 40% adults Eskimos 54% adults Family history Spina bifida occulta? Athletes with repetitive hyperextension Gymnasts Divers Football offensive linemen Pole vaulters Weight lifters Wrestlers LAXers!
Slide 12 - Spondylolysis:Presentation Low back pain, typically at belt line Insidious onset, may increase with activity Rarely radiating Commonly in preadolescent growth spurt Usually no hx trauma Usually no neuro deficits
Slide 13 - Spondylolysis:Physical Findings Hyperlordosis Vertical sacrum Iliac crests high, ribs look low “Short” torso +/- “Step-off” at L5 +/- Facet joint tenderness Hamstring spasm – classic in adolescents! Phalen-Dickson sign (hip-flexed, knee-flexed gait)
Slide 14 - Lumbar Hyperextension Test
Slide 15 - Spondylolysis:Diagnosis X-Ray: First-line! SPECT: If films negative but H&P suggestive CT: If SPECT positive but dx inconsistent Bone Scan: If suspected acute pars fx MRI: If neuro involvement
Slide 16 - Plain Films Oblique X-ray: “Collar” of Scottie dog Greyhound sign PA/Lat X-ray: Contralateral sclerosis
Slide 17 - Scottie Dog
Slide 18 - Spondylolysis:Proposed Classification Type I: Dysplastic Type II: Developmental Type III: Traumatic A: Acute B: Chronic Stress reaction Stress fracture Type IV: Pathologic
Slide 19 - Treatment Depends on SLIPPAGE and SYMPTOMS and SKELETAL MATURITY Spondylolysis and Grade I Spondylolisthesis (<25%): Regular activity. PT. Annual x-rays. Grade II (25-50%): Activity restriction. PT. Re-eval 3-6mo. Grade III (50-75%) - Grade IV (>75%): Surgery for >50% slippage, or >30% in skeletally immature pts; progressive slippage, persistent pain, or neurological symptoms.
Slide 20 - Conservative Treatment Activity restriction NSAIDs Physical therapy Abdominal/back strengthening Hamstring stretching Bracing/Casting Symptomatic Acute pars fx
Slide 21 - ppt slide no 21 content not found
Slide 22 - Conclusions Don’t dismiss a patient with back pain Rule out Red Flags Full ortho & neuro exams Start with plain films Spondylolysis is the most commonly diagnosed organic cause of back pain, and is easily treated!
Slide 23 - References Behrman RE & Kliegman R. Nelson Essentials of Pediatrics. Philadelphia: WB Saunders, 1990. Hay WW, Hayward AR, Levin MJ, & Sondheimer JM. Currents Pediatric Diagnosis and Treatment, 16th ed. New York: Lange, 2003. Wiesel SW & Delahay JH. Essentials of Orthopaedic Surgery, 2nd ed. Philadelphia: WB Saunders, 1997. DeWolfe C. Back pain. Pediatrics in Review 2002;23(6):221. Nigrovic PA & Wilking AP. Overview of the causes of back pain in children and adolescents. UpToDate Online 13.2 April 2005. Nigrovic PA & Wilking AP. Evaluation of the child with back pain. UpToDate Online 13.2 April 2005. Smith JA & Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am 1999;30(3):487-499. Herman MJ & Pizzutillo PD. Spondylolysis and spondylolisthesis in the child and adolescent: a new classification. Clin Orthop 2005;434:46-54.